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How to Appeal a Denied Workers’ Comp Claim

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Posted By DAM Firm | August 19 2020 | Workers' Compensation

Recovering financial benefits through your state’s workers’ compensation program should be relatively easy. It is a no-fault system put in place for your benefit as an employee. If you get injured on the job in California, your employer’s workers’ comp insurance provider should send you a check for your losses within a few weeks. Unfortunately, not every workers’ compensation claim is so simple. You may have additional obstacles to overcome, such as appealing a denied claim.

Collect All Relevant Information

The more information you have about your accident and injury, the stronger your appeal will be. Collect as much information as you can about what happened, including basic facts such as the date and time of your injury, injury location, your first calendar day of missed work, your fifth day of missed work (the date you become eligible for missed wage payments), and the date you first went in for medical treatment. Document all the details related to your injury as well.

  • Name of your physician
  • Official diagnosis of injury
  • Body part injured
  • Images, scans and x-rays
  • Treatment plan
  • Prescriptions
  • How long your injury will take you out of work

You should also learn more about your employer’s insurance plan. Ask for a copy of the policy from your employer, if possible. Read about coverage and how to handle the claims process. Obtain a copy of your initial claim to damages to see if you forgot or missed any vital information. You will need as much information about your accident and claim as possible to use during an appeal.

Find Out the Reason for the Denial

If an insurance company denies your workers’ compensation claim, it must give a reason attached to the denial. If it did not, call the company and ask for a reason. Common reasons for claims denials include alleging that the injury did not happen at work, saying it was a pre-existing injury, saying you caused the injury through recklessness or disputing that you have a disability. Once you identify the reason for the denial, you or your workers’ compensation attorney in San Bernardino can take steps to prove the insurance company wrong. You may simply need to provide a requested document or give further information for the company to change its mind.

Ask for an Internal Review and Reconsideration

The next step to appeal is to ask the insurance company to reconsider its decision. This tactic will generally work best if you provide further information, such as better documentation of your injury and work-related accident. The insurance company may agree to look closer at your claim and reverse its decision. If this does not work, your lawyer can help you file a formal appeal.

Initiate the Formal Appeals Process

You or your attorney will have to request an appellate hearing before the Workers’ Compensation Appeals Board judge in your county. This hearing will be a more informal version of a trial, in which the judge will hear your side of the case as well as that of the workers’ compensation insurance company. The judge will then decide whether the insurer should accept or deny your claim. If the judge sides in favor of the insurance company, your lawyer could then appeal this decision at a higher court.

The appellate hearing typically disputes whether or not your injury claim is compensable. A judge will look at whether the employer’s insurance covers your injury or illness, as well as whether the company should be liable based on the facts of your case. To request an appeal hearing, you or your lawyer must file the Declaration of Readiness to Proceed Form. The courts will then arrange a hearing date with or without a pre-trial conference. An attorney in San Bernardino can help you with all the steps it takes to appeal a workers’ compensation claim denial and obtain benefits in California.

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